In a small study, greater emergency department crowding was tied to higher levels of 1-month PTSD symptoms (Β=2.0, P<0.05) induced by ACS, according to Donald Edmondson, PhD, of Columbia University Medical Center in New York City, and colleagues.

These results remained significant after adjusting for patient characteristics (Β=2.5, P=0.01) and length of stay (Β=3.0, P=0.02), they wrote online in a research letter in JAMA Internal Medicine.

They noted that a recent meta-analysis showed 12% of ACS patients with ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina had PTSD symptoms tied to the patients' ACS. The PTSD symptoms, in turn, were associated with a doubled risk of ACS recurrence and mortality in 1 to 3 years.

To study this association, the researchers conducted an observational cohort study of 135 patients presenting with ACS at emergency department admission from 2009 to 2011 as part of the PULSE (Prescription Use, Lifestyle, Stress Evaluation) study.

Emergency department crowding was grouped into tertiles ranging from low, to medium, to high.

Mean length of stay was 11 hours. Patients had a mean age of 63.3, were mostly male (72%), and were mostly Hispanic (47%).

About a third (32%) had non-STEMI, 13% had STEMI (13%) and 16% had a left ventricular ejection fraction (LVEF) of less than 40%. Unstable angina was seen in 55% 33% had a previous MI (33%).

Patients had a mean Charlson comorbidity index score of 1.8 and a mean in-hospital Beck Depression Inventory score of 8.4.

Those patients treated at more crowded emergency department had significantly higher levels of PTSD symptoms at the 1-month follow-up.

These results remained significant after adjusting for all demographic factors as well as LVEF of 40% or higher.

Further adjustment for length of stay also did not make the results less significant in the subgroup of 99 patients who had all available length-of-stay data recorded, they wrote, adding that "a sensitivity analysis restricted to the 118 patients with non-STEMI and unstable angina yielded nearly identical results."

They hypothesized that potential mechanisms of action may include an increased life threat and decreased control associated with the more-chaotic environment, as well as poor patient-practitioner communication, which they said was associated with PTSD in other patient populations.

The authors noted that their results underscore "the need for hospital administrators and policymakers to address emergency department overcrowding."

They also noted that their study was limited by a small sample size and data from a single emergency department.

In an accompanying editorial, Patrick O'Malley, MD, MPH, of Walter Reed Army Medical Center in Washington, D.C., emphasized that the emergency department environment can be "extremely frightening" and that, to respond to this fear, healthcare professionals should "build structures and develop processes that make it easier to care for patients in optimal environments."

"At the very least, our environments of care should not be contributing to morbidity," he concluded.

MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.

Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) and Continuing Education (CE) credits at no cost for participating in MedPage Today-hosted educational activities.